The Back to Sleep Initiative, Tummy Time, and Container Babies

Understanding Tongue Tie from Birth Onwards – Post 7

In this post, I will discuss how many babies are detrimentally affected by the way they spend their time immobilized. The connection with the series goes back to the bodywork post. All of the tension from things mentioned in this post is even more detrimental in a baby with a tongue tie (as they already have significant tension in the floor of the mouth affecting breathing and eating.) Some of the tensions are very visible, some not as much, but if your baby falls into the categories below, and has a tongue tie, please keep in mind how important the pre and post care is for them. I hope this post will help and inform parents about these issues and will help increase understanding as to WHY babies, almost all babies, would benefit from “bodywork”.

In the 1980s and 1990s, concern was ramping up about sudden infant death syndrome, or SIDS, also known as cot death. This is the rare but tragic unexplained death of a child who is less than a year old, typically during sleep. For a long time, it was not known what was causing these deaths, until a researcher noticed that rates of SIDS varied considerably around the world and the condition was much less common in China. In HongKong, researchers noted that babies were to put to sleep in the traditional Chinese way, on their backs. This was a clue that there could a relationship between sleeping on their fronts and SIDS, thought to be due to the levels of deep sleep that babies achieve when sleeping on their fronts versus their backs.

In 1992, the American Academy of Pediatrics (AAP) advised parents in the US that they should have their babies sleep on their backs to lessen the risk of SIDS, though this was not based on any rigorous study. To raise awareness of this recommendation, the US National Institute of Child of Health and Human Development started a campaign in 1994 then called Back to Sleep (BtS). Because of many documented detrimental issues, such as plagiocephaly and torticollis, counties are reconsidering this guideline and it is now called Safe to Sleep. Throughout the 90s the campaign was highly visible, including advertisements on the television, a leaflet with information for new mothers, and letters which were sent to doctors and nursing officers, all of which advised on the new sleep protocol.

The Back to Sleep campaign was thought to be highly effective and has informed a generation of parental attitudes to infant sleep. At the same time measures were launched to keep babies safe. which I will discuss below. All of these changes happened almost simultaneously so it is not fair to say the “Back to Sleep” campaign was the reason for the decrease in SIDS in that time frame. As a result, of all the harmful things babies have suffered which are documented and irrefutable, recently many practitioners and parents have started to question whether the advice given by the campaign is really scientifically sound and whether putting babies on their backs is the best for babies. (Keep in mind, no other mammal sleeps on their back.) Overall, the initiative has radically altered the way parents think about their babies sleeping, in some positive ways but also in some negative ways.

In this post, I’ll talk about the BtS initiative and the drawbacks for babies who don’t spend enough time on their stomachs. As mentioned above, lacing an infant solely on their back has since proven detrimental to their structures (plagiocephaly, torticollis) neurological integration, neuromuscular development, and overall skeleton muscular system, further complicating the plight of infants suffering from tongue tie.

Other recommendations concurrent with Back to Sleep
In addition to the advice that babies should be put to sleep on their backs or sides to decrease the risk of SIDS, there were other recommendations for baby’s sleeping environments that were put out at the same time as well. This information was put out as part of several overlapping campaigns to inform parents about SIDS and how to mitigate it.

In order to avoid suffocation or strangulation,
parents were advised by the Foundation for the Study of Infant Deaths and
similar groups to:

  • Use a firm, tight-fitting mattress
    for the baby crib
  • Remove soft bedding like fluffy
    blankets, pillows, or stuffed animals from the crib
  • Remove crib bumpers that line
    the inside of a crib
  • Use a modern crib with a safety
    certification seal (keeping width of slats safe and less volatile paints and
    stains used)
  • Never leave a baby sleeping in
    a car seat or upright container (recently rock and plays were totally recalled
    because of this danger

These precautions all make it much less likely
that a baby will roll into something soft and suffocate, get something caught
around their neck, or be injured in various ways.

In addition, further advice was given to parents
about the dangers of babies overheating, especially about bundling babies in
too many clothes and about not leaving babies in a car where the temperature
can rise very quickly. Parents were also informed about the dangers that their
smoking could cause to their child and were advised to give up cigarettes.

Effectiveness of the Back to Sleep Initiative
The BtS campaign succeeded in reaching parents through many different avenues. A study from 1995 found that mothers learned about the BtS recommendations from all sorts of sources, including from doctors, health visitors, and midwives, as well as from television and magazines.

Manufacturers of baby products have also taken
note of these guidelines, and changed their products accordingly. This includes
putting warning labels on soft furnishings like pillows and blankets, stating
that they should not go into a crib; as well as discontinuing production and
sale of top and bottom sheets for cribs, as top sheets are unnecessary and can
pose a choking hazard.

Since its launch, the BtS initiative’s recommendations have become widely adopted and SIDS has been combatted, with rates falling from nearly 4,700 infants dying of SIDS in 1993 to a rate of 2,063 in 2010. Undoubtedly the incidence of SIDS has been reduced by the BtS advice, which is an excellent outcome.

On their backs or other factors?
However, there are questions about whether the reduction in SIDS deaths is actually related to back sleeping, or whether it can be attributed to other factors. The first issue is the way that SIDS is diagnosed, which is not consistent throughout the world because we do not have a firm definition of the condition.

Another notable factor is that SIDS cases were actually declining in the US even before the BtS campaign began. This decline could be due to a variety of other factors, like parents monitoring their babies more closely during sleep, thanks to a generally increased awareness of SIDS. Overall, the evidence is rather weak that there is a direct relationship between sleeping position and SIDS.

I don’t mean to imply that the BtS campaign was not useful! Quite the contrary – I believe that the advice for parents to remove suffocation hazards from babies’ cribs has been a tremendous influence for the better health and safety of children. The raised awareness of sleeping dangers for babies has led to stricter safety standards, as well as more care is taken over serious threats like suffocation, overheating, and secondhand smoke. My doubts – shared by many other health professionals – are over whether putting babies to sleep on their backs is really the silver bullet against SIDS that it has been portrayed to be.

SIDS can occur from suffocation, in which case the guidelines will be very helpful to protect babies, but it can also be centrally mediated, meaning that the baby’s brain fails to direct the body to breathe. Putting a baby to sleep on their back is an effective way to protect them from this kind of centrally mediated SIDS.

The natural way for babies to sleep
As mentioned previously it’s notable that mammals almost always sleep on their sides or on their fronts, and in natural environments, humans are no different. The way that we sleep has changed greatly due to the common availability of soft mattresses and pillows which encourage lying on the back. But, in cultures where these amenities are not common, people most often sleep on floor mats on their fronts. In other words: tummy sleeping is the biological norm.

In addition, most mammals are naturally “co-sleepers”, meaning that youngsters sleep together with their parents. Despite modern recommendations against co-sleeping due to the risk of smothering, some parents do still choose to sleep alongside their babies.  Also, the recommendation is changing as seen in the “Safe to Sleep” campaign, to allow for biologically normal sleeping in a safe environment.  We still have much to learn in our modern lives, with modern comforts, but it is possible to safely co-sleep. 

The reason that co-sleeping is healthy and
natural is that babies’ bodies self-regulate in a number of ways, one of which
is by listening to and feeling the breathing of their mother. Sleeping nearby
thus helps babies to rest better. This is further supported by the importance
of skin-to-skin contact for babies, which helps with their neurological
regulation. It’s also normal for babies to wake up every two to three hours to
feed, which is certainly inconvenient for the mother, but healthy for the baby.
Formula-fed babies take longer to digest their food, which means they sleep
longer – but sleeping too much can cause developmental issues and actually puts
them at higher risk of SIDS.

The American Academy of Pediatrics and other medical bodies have traditionally put out statements opposing bed-sharing between parents and babies, although recently the AAP changed its recommendations to encourage room sharing (but not bed sharing) for no less than the first year of a baby’s life.  Putting a young baby in a different room increases their risk of SIDS.

The problem of swaddling
Another practice that has become common since BtS is swaddling, in which babies are wrapped up tight in rolls of fabric. As you can imagine, this massively limits the baby’s movements and forces them to stay in one position for a long time. Without the freedom to move as they need to, babies can develop all sorts of mobility issues.

Two issues that I see often are positional plagiocephaly, also known as a flat head syndrome; and torticollis, which is where the head or neck is in an asymmetrical position, caused by muscles on either side of the neck is too long or too short. Referrals for such conditions have increased dramatically in recent years, and the incidence of these conditions is thought to be related to both swaddling and sleeping on the back.

When I see babies with these issues in my practice, I mention the problems with swaddling to parents. But many parents have been told by their pediatrician that it’s fine. The problem here is that pediatricians generally assess the baby’s development by measuring the circumference around their head, without taking in account other issues like the overall shape and look of the cranium, nerve dysfunctions, whole-body tensions, and developmental delays which are associated with positional plagiocephaly. These conditions are directly related to the BtS recommendations and are exacerbated by them.

Dangers of container babies
Allowing babies to move freely is tremendously important not only for their development but also for their safety. Nowadays it’s common to see “container babies” who are routinely taken from sleeping on their back and put straight into a physical container like a “rock and play” where they could spend up to 8 or 9 hours a day. When babies are placed in these containers they will sometimes sleep, which parents take as an indication that the baby is relaxed – but in fact, this is dangerous for the baby’s health.

Of course, sometimes it’s necessary to restrict a baby’s movement, such as putting them in a car seat while you are driving. But a baby should not be in a container for more than 10 minutes at a time. In fact, car seats are some of the most dangerous threats to babies in terms of the position that they are held in. Car seats carry a significant risk of shutting off the airway as the neck is not supported. There have even been tragic cases where babies have died after being carried in from the car still in their seat and left to continue sleeping.

In order to develop mobility and to get the
kinesthetic stimulation they need, babies need to move around and learn to use
their limbs and their senses; not restricted into a small container
where they do not have neck support, and can suffer from airway issues.

Counteracting BtS: Tummy time
As awareness about the limitations of the BtS recommendations has grown in the medical community, a new approach has been gaining traction: tummy time. Developed by pediatric occupational therapist Michelle Price Emanuel, the approach encourages parents to put babies on their fronts for periods of time in order to develop their sensorimotor skills.

Much of babies’ first six months is spent
learning reflexive movements. Think of a newborn baby with a rattle – they
don’t decide to shake the rattle (that would be volitional movement), they
simply jerk about reflexively. This is a key part of their learning process,
and over 90 percent of reflexes in this time happen only when the baby in on
their tummy. Spending time on their tummies is key for developing retained
primitive reflexes (movement skills), neurological integration, sensory
integration, and sensory processing. This time also helps to lengthen and
strengthen all of the muscles in the neck which are key for feeding and

Babies often resist being on their tummies at
first, especially if they are not used to it, so parents need to learn how to
manage this grumpiness. The Tummy Time initiative hosts drop-in class where
parents and babies can learn these skills together. If there is not a class
available near you then a physical therapist or occupational therapist with
training in infants can help too.

The tummy is the most natural and safe place for a baby to be, and tummy time is essential for babies’ development. In fact, even the AAP who put out the BtS recommendations says that babies should spend much of their waking time on their tummies! Take it from them: “a certain amount of prone positioning, or ‘tummy time,’ while the infant is awake and being observed is recommended to help prevent the development of flattening of the occiput and to facilitate the development of the upper shoulder girdle strength necessary for timely attainment of certain motor milestones.”

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